Munchausen by Proxy Syndrome

By the time she was 8 years old, J.B. had been hospitalized 200 times and had undergone more than 40 operations, including the removal of most of her intestines.

K.C., a 2-year-old boy, was hospitalized more than 20 times due to complications from asthma, severe pneumonia, mysterious infections, and sudden fevers. His doctors were baffled and unable to determine the cause of these illnesses.

In a family with five children, one after another died of sudden infant death syndrome (SIDS).

What do these seemingly unrelated cases have in common? All were the result of Munchausen by Proxy Syndrome (MBPS), or Factitious Disorder by Proxy, as it is listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This condition involves the exaggeration or fabrication of illnesses or symptoms by a primary caretaker. J.B.'s medical history was traced to her mother, who manufactured her daughter's illnesses. Similarly, when K.C. was thought to have AIDS, he eventually complained to his mother's friend that his thigh was sore because "Mommy gave me shots." And 23 years after the five babies in one family died, it was determined that SIDS was not the cause, but murder.

What Is MBPS?
In MBPS, an individual - usually a mother - deliberately makes another person (most often an infant or toddler) sick or convinces others that the person is sick. She misleads others into thinking that her child has medical problems by lying and reporting fictitious episodes. She may exaggerate, fabricate, or induce symptoms. As a result, doctors usually order tests, try different types of medications, and may even hospitalize the child or perform surgery to determine the cause.

Typically, the mother knows that these procedures are not needed, but she feels satisfied when she has the attention and sympathy of doctors, nurses, and others who come into contact with her and her child. Because she appears to be so caring and attentive, often no one suspects her. It's not unusual for medical personnel to overlook the possibility of MBPS because it goes against the belief that a mother would never deliberately hurt her child.

One of the most harmful forms of child abuse in more extreme cases, MBPS was named for Baron von Munchausen, an 18th-century German dignitary known for telling outlandish stories. A perplexing aspect of the syndrome is the ability of the mother to fool and manipulate doctors. Because it can take so long for doctors to identify the syndrome, some children may die as a result of MBPS without a diagnosis being made.

If a doctor or health care provider suspects MBPS, he would look for signs and symptoms of the disorder, which include:
o a child who has multiple medical problems that do not respond to treatment or that follow a persistent and puzzling course
o physical or laboratory findings that are highly unusual, discrepant with the child's medical history, or physically or clinically impossible
o acute symptoms that tend to cease when the perpetrator is absent
o a parent or caregiver who is not reassured by "good news" when test results find no medical problems, but continues to believe that the child is ill
o a parent or caregiver who appears to be medically knowledgeable or fascinated with medical details or appears to enjoy the hospital environment
o a parent or caregiver who is unusually calm in the face of serious difficulties in her child's health
o a parent or caregiver who is highly supportive and encouraging of the doctor, or one who is angry and demands further intervention, more procedures, second opinions, or transfers to more sophisticated facilities

It's important to remember that MBPS is a relatively uncommon disorder. More often than not, a child with a mesmerizing medical history or frequent hospital visits does have an underlying medical condition that has eluded the health care team. MBPS may be suspected in some of these cases, but that does not mean it is the actual diagnosis.

What Causes MBPS?
Scientific studies have been unable to establish a clear psychological profile of the people who perpetrate this abuse. In some cases, the mothers themselves were abused, both physically and sexually, as children. Other theories say that MBPS is a cry for help on the part of the mothers, who may be experiencing anxiety or depression or have feelings of inadequacy as parents of young children. Some mothers may feel a sense of acknowledgement when their child's doctor confirms their parenting skills.

The suspected parent may have symptoms similar to her child's own medical problems or an illness history that is puzzling and unusual. She frequently has an emotionally distant relationship with her spouse, and the spouse often fails to visit the seriously ill child or have contact with doctors. Lastly, the parent has a great need for recognition of her care-taking abilities.

"There are various theories, but most boil down to a need for attention, especially from health care personnel. Mothers may have come from families in which sickness was a way to get love. Their own needs overwhelm their ability to see the child as a person with feelings and rights. Perhaps they were not treated as a person with feelings and rights when they were children. Anger may be involved, either at the child or toward the people who are manipulated by the behavior. They may be seeking help, or they may vicariously enjoy the attention that the sick child gets," explains Mary Sheridan, PhD, ACSW, a professor of social work in the division of arts and sciences at Hawaii Pacific University.

Some experts theorize that MBPS represents a spectrum of disorders and that the cases most people are familiar with - because they tend to be on TV or elsewhere in the news - are the more extreme examples of the syndrome. According to Leslie Gavin, PhD, a psychologist, MBPS is a form of child abuse and may be broken down into four categories:

1. Parents of vulnerable children - a child may be born with a medical problem or have a chronic condition, and the parent may subsequently see the child as being vulnerable to illness and become hypervigilant (this is not technically child abuse).
2. Illness exaggerators - a child may have a medical condition, but the parent exaggerates it.
3. Illness fabricators - the parent lies to doctors about symptoms or fabricates things, such as a history of fevers.
4. Illness inducers - this category represents the types of cases that are the most publicized but are actually the most rare; they involve the parent making the child ill by means such as suffocating, injecting foreign substances into IVs, or poisoning food.

What Happens to the Child?
In the most severe instances, parents with MBPS may go to great lengths to make their children sick. When cameras were placed in some children's hospital rooms, mothers were filmed switching medications, injecting their children with urine to cause an infection, or placing drops of blood in urine specimens. One mother was taped injecting nail polish remover into her daughter's feeding tube. Another suffocated a child to the point of unconsciousness, then frantically rushed him to medical personnel for attention.

Some parents aggravate an existing problem, such as manipulating a wound so that it doesn't heal. One parent discovered that scrubbing the child's skin with oven cleaner would cause a baffling, long-lasting rash.

However, if MBPS is considered as a spectrum, not all the cases are so graphic. The parents of a child who was born prematurely and initially had some medical problems may not be able to accept that their child is fine by the time he is a toddler. They may continue to rush him to the doctor practically every week with imagined concerns.

Parents who exaggerate about their child's symptoms may claim that a child who has only mild asthma turns blue whenever he has an asthma episode. Those who go one step further make up symptoms (not to be confused with causing them), such as bringing in a false "record" of times when the child ran a fever.

Whatever the course, the child's symptoms - whether induced or fabricated - do not occur when the parent isn't present, and they usually resolve during periods of separation from the parent. When confronted, the parent invariably denies knowing how the illness occurred.

The long-term prognosis for these children depends on the degree of MBPS. Some extreme cases have been reported where children developed destructive skeletal changes, limps, mental retardation, brain damage, and blindness from induced symptoms. Often, these children require multiple surgeries, each with the risk for future medical problems.

If the child lives to be old enough to comprehend what is happening, the psychological damage can be significant. He may learn that he will only be loved when he is ill and thus may aid in the deception, using self-abuse to avoid abandonment by his mother. In this way, some victims of MBPS later become perpetrators themselves.

Getting Help for a Child
When abusive MBPS is suspected, health care providers are required by law to report their concerns. But because the syndrome is so hard to prove, medical personnel may be reluctant to get involved for fear of litigation. Nevertheless, as in other child abuse cases, ensuring the safety of the child is the top priority. After a parent or caregiver is charged with MBPS, the victim's symptoms may increase as the person who is accused attempts to prove the presence of the illness. If the parent or caregiver repeatedly denies the charges, the child should be removed from the home and legal action should be taken on the child's behalf.

In some cases, the parent or caregiver may deny the charges and move to another location, only to continue her behavior. Even if the child is returned to her custody while children's protective services are still involved, the child may continue to be a victim of abuse. For these reasons, it is always advised that these cases be swiftly resolved.

Getting Help for a Parent
Unless a parent admits to the abuse, psychological treatment has little chance of remedying the situation. Psychotherapy depends on truth, and MBPS perpetrators generally live in denial. Most often, abusive MBPS cases are resolved in one of three ways:
o the apprehension of the perpetrator
o the perpetrator moves to a younger child when the original victim gets old enough to "tell"
o the death of the child

"Family and friends can assist by encouraging the perpetrator to own up to the deceptions and to approach psychotherapeutic work with seriousness and honesty. However, barring an admission on the part of the perpetrating individual, mental health treatment has essentially no chance of being effective, [and] the home situation will probably never be sufficiently safe for the return of the abused child," says Marc Feldman, MD, vice chairman of the department of psychiatry at the University of Alabama at Birmingham and coeditor of The Spectrum of Factitious Disorders.